Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 03/19/2018 <br />Name Kieran Fahey Department Engineering <br />L Agreement <br />U Contract U Proposal U Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />M Other: Application form <br />Company or Vendor Name: NA <br />New Vendor <br />❑ Yes ❑ No ❑ if Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Downspout Disconnection "In Lieu of Disconnect Program" <br />Project Number <br />NA <br />Funding Source <br />NA <br />Account No. <br />NA <br />Amount <br />NA <br />Terms of Contract <br />NA <br />Purpose/Description <br />To have the application form for the Downspout Disconnection "In <br />Lieu of Disconnect Program" approved by the BPW. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Regiiiied For Charge Orers Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval - <br />Copy Original <br />11 ❑ <br />